Testimony

Statement by
Julie L. Gerberding, M.D., M.P.H.
Director
Centers for Disease Control and Prevention
Administrator
Agency for Toxic Substances and Disease Registry
U.S. Department of Health and Human Services
on
CDC's Terrorism and Global Diseae Detection Efforts
before the
Subcommittee on Labor, Health and Human Services, Education, and Related Agencies

April 28, 2004

Good morning, Mr. Chairman and members of the Committee. I am Dr. Julie Gerberding, Director of the Centers for Disease Control and Prevention (CDC) and Administrator of the Agency for Toxic Substances and Disease Registry (ATSDR). It is such a pleasure to be back to testify before your subcommittee again this spring. Our mission, as part of the Department of Health and Human Services, is to protect the health and safety of the American people through activities that range from terrorism preparedness and response, to promoting worker safety, to preventing birth defects and limiting the spread of infectious diseases. Thank you for the opportunity to join you today and testify today about CDC's specific efforts in terrorism and global disease detection.

These responsibilities require a strong strategic focus that allows CDC to balance emerging issues with our vision for safer, healthier people in every community. Thus, in June 2003, I initiated an agency-wide strategic planning process to transform CDC into a substantially more integrated, adaptive and highly effective organization. This outside-in, customer-focused process, termed the Futures Initiative, is guiding CDC's efforts to meet the public health challenges of this and future generations.

CDC's central governing principle is undergoing a fundamental reshaping in the process, moving us away from a focus on disease control to a more holistic aim of health protection. Two health protection goals are driving this reshaping: (1) Health Promotion & Prevention of Disease, Injury, and Disability; and, (2) Preparedness. The first of these goals will assure that all people achieve their optimal lifespan with the best possible quality of health in every stage of life. The second, that people in all communities will be protected from infectious, environmental, and terrorist threats. Over the long term, the Futures Initiative will assure agency readiness to confront traditional and emerging public health threats with equal vigor.

We continue to make vast strides toward achieving optimal terrorism preparedness and emergency response capacity at the federal, state and local level, and CDC's Global Disease Detection Initiative offers a strong platform for enhancing global public health infrastructure. In FY 2005, the President has requested $1.1 billion through the Public Health and Social Services Emergency Fund for terrorism preparedness and $51.3 million, a $27.5 million increase over FY 2004, to expand and accelerate our current global disease detection efforts.

Terrorism

CDC is committed to strengthening the capacity of the public health system to respond to both routine and emergent health threats. To achieve this imperative, we must continue to prepare the broader public health infrastructure at home and abroad to respond to a wide range of public health emergencies.

State and Local Readiness

Today, as a result of the more than $3 billion investment Congress has made over the past three fiscal years, the front-lines of public health are better prepared to detect terrorism and deal with its consequences, and there are specific initiatives underway at CDC and in each state to make America even safer.

In 1999, CDC began a program of providing technical assistance and funding to state, local and territorial public health departments to develop capacity to respond to terrorism events and public health emergencies. In FY 2002, Congress appropriated a substantial increase in funding for this preparedness effort and CDC's state, and local cooperative agreement program has grown rapidly as a result. The resources provided through this cooperative agreement program support 62 grantees in the development of critical public health preparedness capacities, including preparedness planning and readiness assessment; surveillance and epidemiology; biological and chemical laboratory capacity; communications systems and information technology; health information dissemination and risk communication; and education and training.

States and localities have made substantial progress toward achieving optimal levels of preparedness since the terrorist attacks of fall 2001. For example, every state has developed an emergency preparedness and response plan and nearly 90 percent of states have trained public health practitioners in responding to terrorism. In addition, every state either has achieved or is moving toward around-the-clock capacity to send and receive critical health information, and 42 states can transmit information among state and local public health officials, hospitals, emergency departments, and law enforcement. CDC's overarching goal in this arena is to have systems in place in each community that protect citizens from infectious diseases, environmental threats, and terrorism, and these achievements represent substantial progress toward that end.

Commensurate with CDC's agency-wide emphasis on rigorous measurement of programmatic impact, CDC will begin pilot testing performance indicators in FY 2004 in an effort to better define and establish a fundamental level of public health preparedness. The data generated by these standardized indicators will provide a framework for future cooperative agreement guidance, allow for accurate evaluation of grantee progress, and enable more targeted technical assistance. Moreover, these data will make an essential contribution toward defining what it actually means to be "prepared" at the state or local level. CDC anticipates incorporating the goals, objectives, and measures of this performance indicators effort into the state and local cooperative agreement guidance for FY 2005.

Biosurveillance Initiative

The President's budget request for CDC includes $1.1 billion in FY 2005 through the Public Health and Social Services Emergency Fund to continue to strengthen terrorism preparedness capacity at the federal, state and local levels. Included in the request is $130 million for a new biosurveillance initiative that will fill a significant gap in surveillance and early warning of a potential terrorist attack or infectious disease outbreak.

The biosurveillance initiative involves three distinct but interrelated elements. The first, known as BioSense, is a state-of-the-art, multi-jurisdictional data sharing initiative that will improve the nation's capabilities for near real-time disease detection and surveillance by using data from existing health databases. This data sharing effort will support early detection of potential terrorism events while minimizing the reporting burden for state and local health departments and clinical personnel.

The second element centers on the addition and expansion of quarantine stations at U.S. ports of entry and assigning multidisciplinary teams of quarantine officers, public health advisors, epidemiologists, and information technicians to these sites. This effort will assure effective monitoring of U.S. and international regulatory requirements for travelers, rapid communication of disease intelligence information to federal, state, local and international partners, and consistent supervision of clinical and research material movement through ports of entry.

The Laboratory Response Network, which serves as a point of integration for federal, state, local and territorial laboratories to ensure rapid and proficient laboratory diagnosis of emerging bioagents and environmental contaminants, is the third and final component of the biosurveillance initiative. Additional resources in FY 2005 will allow the Laboratory Response Network to expand its reach into food safety and animal diagnostic labs, thereby strengthening the nation's laboratory infrastructure for timely and accurate reporting of a potential bioterrorism attack.

The biosurveillance initiative is part of an interagency effort that crosses multiple sectors, including food supply, environmental monitoring, and human health surveillance, and its benefits will be felt in all state and local health departments. By integrating these otherwise isolated data sources, potential public health emergencies that may have gone undetected can be identified more rapidly. Through the biosurveillance initiative and ongoing capacity-building efforts at the state and local levels, the FY 2005 budget request will continue to enhance frontline emergency preparedness.

Global Disease Detection

Through the Futures Initiatives, CDC is establishing clear priorities for its global health programs and is increasing global connectivity to ensure rapid detection and response to emerging health threats. CDC has been involved in diseases of international importance since its post-World War II origins as a malaria control center. In the 1960s, we became integrally involved in smallpox eradication. Today, that tradition continues as CDC supports a variety of initiatives designed to prevent diseases around the world. Recent experiences with the SARS, monkey pox, and avian influenza outbreaks, as well as bioterrorism events, have starkly highlighted the threats of emerging and re-emerging infections to human health, the global economy, and to national security.

International e-CDC

CDC's Global Disease Detection activities are focusing on three goals. First, we are developing an international e-CDC, which will consist of CDC extension offices around the world that will work with the governments in which they are based and global businesses to achieve global health goals. This collection of CDC offices, foreign public health agencies and businesses will be linked electronically to enhance global disease detection and other health goals. A robust and sensitive disease detection network will provide an answer to the question, "How do we know when something unusual is going on?" An effective system demands an intricate web of interconnected laboratories and connections to clinicians, pharmacies, veterinarians, and others, across a variety of disciplines that must be provided an accessible and reliable way to provide information.

On a multinational level, we will continue to collaborate with the WHO, one of CDC's key global partners, through the Global Outbreak Alert and Response Network (GOARN) to assure overall improvements in global disease detection and control. This network has demonstrated the value of novel and unconventional surveillance systems that are based on news media reports. Artificial intelligence tools scan Internet news feeds for disease reports in multiple languages. WHO then rapidly verifies these reports with health officials in the affected country. Other global health partners include The World Bank where our collaborations may play a critical role in shaping future investments and business development and UNICEF, an ally in CDC's global immunization activities.

In addition to our domestic, bilateral and multinational collaborations, CDC plans to create similar networks with multinational corporations abroad. International firms often have well developed communications systems and humanitarian and economic interests in protecting the health of their workers that can help inform CDC's plans of action in particular countries.

A critically necessary application of a strong disease detection system involves tracking the influenza virus. In the event of an influenza pandemic, CDC estimates that a range of 89,000 to 207,000 excess deaths and 314,000 to 734,000 hospitalizations could occur in the United States alone without investment in prevention efforts. The economic impact could range from $71- $167 billion. The early detection of variants of influenza virus and the rapid development of data on their spread are critical in determining recommendations for inclusion of new antigenic variants in new vaccines for use worldwide. An effective early detection system is the best hope for controlling this type of potentially-pandemic influenza.

Our global disease detection program includes enhancing the national influenza surveillance programs in at-risk countries, formally electronically linking with the World Health Organization (WHO) global flu surveillance network, conducting avian influenza transmission studies to better understand factors leading to emergence of the influenza virus and educating domestic and international health care and emergency workers about how to best to detect and respond to influenza outbreaks. FY 2005 funding for global influenza detection will also support the improvement of an early warning system for the identification of novel influenza viruses for optimal decision making on vaccine strains and funding and research on new viral strains to improve vaccines and vaccine candidates for viruses with pandemic potential.

Sentinel Sites

Our second global disease detection goal is to fortify CDC sentinel sites by strengthening their laboratory and epidemiology capacities. Sentinel Sites are key global locations in which CDC deliberately places staff to enhance collaborations, laboratory science, and epidemiology capacity, and to provide in-country training. As of 2004, there are 9 sentinel sites of geo-strategic importance. Six of these sites are based in the countries of Bangladesh, Brazil, Egypt, Guatemala, Kazakhstan, Kenya, Peru, Singapore, and Thailand. The sentinel sites use laboratory science and field epidemiology to detect the existence of new diseases, new strains of infectious microorganisms, and re-emerging diseases in the population. In addition, they provide advanced training and build communication mechanisms for epidemiologists and laboratory scientists to promote effective, functional research by building a network of Field Epidemiology and Laboratory Training Programs (FELTPs).

Rapid Response

Ultimately, even the best disease detection and laboratory science will not protect citizens' health unless it is paired with an effective public health system that acts on the information it collects and that shares important risk information with partners, communication channels (such as the news media), and the public. Therefore, CDC's third global disease detection goal is to build and bolster CDC rapid response teams consisting of existing Epidemic Intelligence Service (EIS) officers and, when needed, a new International Reserve Unit of retired CDC personnel to act as global disease detectives' when outbreaks occur throughout the world.

To better equip our health care and emergency workers, we will utilize distance education to share information immediately with large audiences worldwide. For example, during the SARS outbreak, CDC was able to assemble a panel of WHO, CDC, and other global experts and communicate live from a studio in Atlanta, Georgia, to more than 2 million Chinese clinicians. And, as I mentioned a moment ago, our existing outbreak response capacity will be bolstered by the development of the new International Reserve Unit to allow us to mobilize more people in acute outbreak situations. This system will develop an experienced force of retired or inactive "disease detectives" who can be regularly trained to upgrade skills and knowledge, and rapidly deployed when needed.

CDC will continue to work side by side with our partners to make progress on protecting people from infectious, environmental, and terrorist threats. As we continue this work, I want to thank the Committee again for its support and for enabling CDC to protect health.

Thank you very much for your attention. I will be happy to answer any questions you may have.

Last Revised: April 29, 2004